Insight into the precautions to be taken by any Health Care Worker during COVID 19 Pandemic in order to protect themselves and family.

1. Dr Ashwin Menon
MBBS, MS (ENT)
Asst. Professor
ENT Department
KMCT MCH

2. Introduction to the disease…
• The clinical disease termed COVID-19 is caused by a novel beta
coronavirus, now renamed as SARS-CoV-2.
• The SARS-CoV-2 is the seventh Corona virus known to infect
humans.
• Was declared a global pandemic by WHO on March 11th 2020.

4. Route of transmission ofCOVID-19

8. When to *Suspect case*
*Suspect case* as *
(a)Any symptomatic individual who has
international travel in the last 14 days
(b)all symptomatic contacts of confirmed cases
(c)all symptomatic HCWs
(d)all hospitalized pts with SARI &
(e)asymptomatic direct and high risk contacts of a
confirmed case ( tested once between day 5
& 14 after contact)*

9. Laboratory testing
• A reverse transcription polymerase chain reaction (RT-PCR) test can
detect SARS-CoV2 in clinical specimens such as blood, stool, and
nasal secretions.
• Serologic testing also can be performed to detect SARS-CoV2
antibodies produced after infection.
• Finally, viral culture has been used to detect SARS-CoV2.

11. Revised Guidelines on Clinical Management of COVID – 19
Government of India Ministry of Health & Family Welfare Directorate General of Health Services
(EMR Division)
• Based on the available information the following drugs may be considered as an
off – label indication in patients with severe disease and requiring ICU
management:
• HCQ (Dose 400mg BD – for 1 day followed by 200mg BD for 4 days) in
combination with
• Azithromycin (500 mg OD for 5 days)
• These drugs should be administered under close medical supervision, with
monitoring for side effects including QTc interval, retinopathy.
• The above medication is presently not recommended for children less than 12
years, pregnant and lactating women

12. Treatment options
• Tocilizumab
• Ivermectin
• Convalescent plasma
• Ritonavir plus Lopinavir combination
• Oseltamivir

15. Who should avoid practicing…
• Doctors and paramedical staff above age of 60 years.
• Those with underlying medical conditions (especially
immunocompromised / predisposing to infections) like:
– DM, CLD, CAD, CKD, Chronic lung conditions like Asthma,
COPD, Bronchiectasis, ILD, etc., Cancer, On Chemotherapy or
Steroid treatment, Pregnant, Seropositive status.

16. Patients to be avoided…
• All symptomatic individuals who have undertaken international
travel in the last 14 days
• All symptomatic contacts of laboratory confirmed cases
• All symptomatic healthcare personnel (HCP)
• All hospitalized patients with severe acute respiratory illness (SARI)
(fever AND cough and/or shortness of breath)

17. Patients to be avoided…
• Asymptomatic direct and high risk contacts of a confirmed case
(should be tested once between day 5 and day 14 after contact)
• (Symptomatic refers to fever/cough/shortness of breath.)
• (Direct and high-risk contacts include those who live in the same
household with a confirmed case and HCP who examined a confirmed
case.)

18. Directly refer for testing…
• All those with patients with any of these things positive should be
referred to the nearby Covid centre for testing. (Government or
Private diagnostic facility)

19. Pregnant and Breastfeeding patients…
• Testing to be prioritized, if suspicion arises
• Currently there is no data suggestive of viral transmission via breast
milk.
• However, due to close contact and risk of droplet transmission,
breastfeeding should be avoided in COVID-19 confirmed mothers.

20. Key concepts
➢Limit how germs can enter the facility
➢Isolate symptomatic patient as soon as possible
➢Protect healthcare workers

21. Triage on phone
• The crucial 1st step in protecting doctors and other patients.
• All patients must be assessed for possible COVID-19 infection and
suspects (as mentioned earlier), if they does not have any of them,
call them to your clinic by appointment, keeping the reasonable time
between each patient as per your discretion to avoid crowding at the
clinic.
• If any patient seems to be Covid suspect, please refer him/her to the
nearby Covid testing center.
• Avoid routine follow ups, elective procedures.
• You may guide the patient on phone for minor issues at your
discretion.

22. Triage at clinic/ Hospital, if possible…
• Triage stations with adequately trained staff should be allotted at the
entrance of each health care facility.
• Physical barriers (glass/plastic barriers) should be installed at these
stations to limit close contact between triage personnel and
potentially infectious patients.
• Use of Personal Protective Equipments (PPE) is preferred.

24. Clinic management…
• Restrict the OPD time to limited hours
• Avoid walk-in patients
• All patients only, avoid relatives as much as possible
• Make the patients wait about 1 meter apart (can make squares)
• If possible, don’t make patient sit anywhere in your clinic
• If patient need to be examined on bed or table, clean it immediately
following the examination.

25. Clinic management…
• Please don’t touch any documents of the patient, just see them from
far. (may ask patients to click photos and send you in advance)
• Use new prescription for all patients ( may have an assistant for the
same)
• While dispensing medicines, prefer no touch techniques with the
patient.

26. Clinic management…
• All patients with respiratory symptoms made to wear a mask in the
waiting area and instructed on cough and sneeze hygiene.
• Doctors clinics should be well ventilated and patients should be
seated and stay six feet apart except during physical examination.
• The doctor should wear a mask and scrub hands with soap and
water and use an alcohol- based disinfectant after each patient
interaction.

28. Display in Clinics…
• Visual alerts should be posted at the entrance and strategic areas
(waiting areas, elevators and cafeterias)
• To reinforce both patients and health care workers, the importance
of hand hygiene, respiratory hygiene and cough etiquette

30. Hand hygiene…
• All health care workers should perform hand hygiene using alcohol-
based hand rub (minimum 20 seconds) or by washing with soap
and water (minimum 40 seconds). If hands are visibly soiled, use
soap and water for hand wash.
• Performed before and after using bathroom, before, during and
after preparing food, before and after eating /drinking, after
coughing, blowing or sneezing, after touching garbage, after
touching mask or soiled PPE.
• Foot operated sanitizers should be put outside elevators, OPDs,
screening areas, ICUs and wards.

32. Need of the protective gears for all?
• Hand hygiene is for all healthcare workers
• Based upon your role in patient management and duration of
exposure with patient (more than or less than 15 minutes), you
have to donn the protective gears.
• Thus, need of protective gears depends upon the place where you
are practicing
• It is classified in following slides…

33. Mask etiquette…
If masks are worn, appropriate use and disposal is essential to ensure they are effective and to
avoid any increase in risk of transmission associated with the incorrect use and disposal of
masks.
i. Place mask carefully to cover mouth and nose and tie securely to minimize any gaps
between the face and the mask
ii. While in use, avoid touching the mask
iii. Remove the mask by using appropriate technique (i.e. do not touch the front but remove
the lace from behind)
iv. After removal or whenever you inadvertently touch a used mask, clean hands by using an
alcohol-based hand rub for 20 seconds or soap and water if visibly soiled for 40 seconds
v. Replace masks with a new one as soon as they become damp/humid
vi. Do not re-use single-use masks
vii.Discard single-use masks after each use and dispose-off them immediately upon removal
viii.For N95 respirators adequate fit check must be performed after wearing.

38. Combined protection…
Combining all measures —
Hand-washing
Masks
Gloves and
Protective gown
(wherever needed)
Increases the
intervention
effectiveness

39. TRANSPORT PROTOCOL
For shifting any suspected or confirmed COVID-19 patients, the
following steps must be followed by the accompanying healthcare
provider:
A.Decontaminate hands (alcohol-based sanitizer/soap)
B.Donn PPE
C. Inform COVID Centre control room regarding the
admission/transfer of a potentially infectious patient.
D.In ambulance
• Use single use or single patient use medical equipment where
possible
• Use disposable linen if available
• Monitor and document vitals and medical management done in
ambulance

40. TRANSPORT PROTOCOL
E. Arrival at COVID centre
• Before the patient leaves the ambulance ensure arrangements are in place for
receipt of the patient
• Transfer patient to the care of hospital staff at Trauma Centre
• After transfer of patient remove PPE
• Perform hand hygiene
F. Before ambulance is used again
• Cleaning and disinfecting (PPE as outlined above should be wor while cleaning)
• Surfaces (stretcher, chair, door handles etc.) should be cleaned with freshly
prepared 0.5-1% hypochlorite solution or equivalent
• Medical equipment should be cleaned as per hospital infectio control protocol

42. Environmental sanitation:
• Immediately remove and wash clothes and bedding that have blood, stool or other
body fluids on them
• Clean and disinfect frequently touched surfaces in the quarantined person’s room
(e.g. bed frames, tables etc.) daily with Sodium Hypochlorite solution (1%) or
ordinary bleach (5%)
• Clean and disinfect toilet surfaces daily with regular household bleach
solution/phenolic disinfectants
• Wash laundry used by the person separately using common household detergent
and dry thoroughly using the warmest temperatures recommended on the clothing
label
• Place all used disposable gloves, masks and other contaminated waste in a closed
container before disposing of them with other household waste and wash hands
with soap and water/alcohol-based hand rub.

43. Duration of home quarantine period…
• Is for 28 days from contact with a confirmed case or earlier if a suspected
case (of whom the index person is a contact) turns out negative on
laboratory testing.
• 2 negative samples 24 hours apart

44. Special precautions to be followed for
aerosol generating procedures
• Include tracheal intubation, non-invasive ventilation, tracheostomy,
cardiopulmonary resuscitation, and bronchoscopy.
• Are all associated with increased risk of transmission of COVID-19
• HCWs conducting such procedures should be wearing full-body PPEs
including N95 particle-filtering masks
• Should be carried out in an adequately ventilated room or in airborne
infection isolation rooms (AIIR) which are negative pressure rooms

46. Access to personal protective equipment
(PPE) for health workers
• Is another key concern.
• Even developed countries like the UK and USA report extreme
shortages, and these concerns are multiplied in parts of the
developing world which may be most hit by the epidemic.
• PPE shortages have been described in almost all affected facilities.
• Many physicians are forced to put themselves at risk and are already
managing these patients using equipment (out of the box ideas)
which does not measure up to standard recommendations.

47. Emotional needs of HCWs
• Must not be ignored
• Health care workers at the front-line of COVID-19 are under extreme
physical and mental stress.
• They are physically overworked beyond conceivable limits,
• They are forced to make tormenting triage decisions,
• Racked by guilt and pain from losing patients and colleagues.
• Additionally, worrying about their own health and the constant
anxiety of passing infection on to their families.
• Suffer from extreme levels of stress, depressive orders, anxiety and
insomnia.

48. Decontamination and waste management
in clinics
• Any surface or material known to be, or potentially be, contaminated
by biological agents must be correctly disinfected to control infectious
risks.
• Proper processes for the identification and segregation of
contaminated materials must be adopted before decontamination
and/or disposal.
• Where decontamination cannot be performed in the laboratory area or
onsite, the contaminated waste must be packaged in an approved (that
is, leak proof) manner, for transfer to another facility with
decontamination capacity.

49. Practices for environmental cleaning in healthcare facilities:
• Environmental cleaning should be applied to all patients in all healthcare
facilities.
• Ensure that cleaning and disinfection procedures are followed consistently
and correctly.
• Cleaning agents and disinfectants-
• 1% Sodium Hypochlorite can be used as a disinfectant for cleaning and
disinfection
• The solution should be prepared fresh.
• Leaving the solution for a contact time of at least 10 minutes is
recommended.
• Alcohol (e.g. isopropyl 70% or ethyl alcohol 70%) can be used to wipe down
surfaces where the use of bleach is not suitable, e.g. metals.

50. Decontamination
• PPE to wear while carrying out cleaning and disinfection works:
1. Wear heavy duty/disposable gloves, disposable long-sleeved gowns, eye goggles or a
face shield, and a medical mask (please see the PPE document for details)
2. Avoid touching the nose and mouth (goggles may help as they will prevent hands from
touching eyes)
3. Disposable gloves should be removed and discarded if they become soiled or damaged,
and a new pair worn
4. All other disposable PPE should be removed and discarded after cleaning activities are
completed. Eye goggles, if used, should be disinfected after each use, according to the
manufacturer’s instructions.
5. Hands should be washed with soap and water/alcohol-based hand rub immediately
after each piece of PPE is removed, following completion of cleaning.
• Where possible, seal off areas where the confirmed case has visited, before carrying
out cleaning and disinfection of the contaminated environmental surfaces. This is to
prevent unsuspecting persons from being exposed to those surfaces. Inform the local
authorities immediately.

51. Decontamination
Frequency of cleaning of surfaces:
1. High touch surfaces: Disinfection of high touch surfaces like
(doorknobs, telephone, call bells, bedrails, stair rails, light switches,
wall areas around the toilet) should be done every 3-4 hours.
2. Low-touch surfaces: For Low-touch surfaces (walls, mirrors, etc.)
mopping should be done at least once daily.

52. • Use only 1 pen, phone and water bottle (disposablebetter)
• Decontaminatephone
• Do not touch anything
• Everything is contaminated unless cleaned in your presence
• No watches no rings no bangles no dangling earrings
• Hairs tied and Cover your head with cap.
• Shift to scrubs full sleeves, if available.
• Empty bowel and bladder before you wear your PPE
• Wear double glove
• Keep your palms together when you see patients to remind you not to
touch them.
• Don't use stethoscope. These are not normal times
• Wear goggles
• Wear masksif patient contact or in busy area
• Wear footwear which covers foot fully. Plastic or rubber easy to disinfect
For all medical professionals (Basics…)

53. For all medical professionals (Basics…)
• Social distancing poorly practiced in hospitals, so please pay attention
• Keep 1 m distance
• No elective job at hospital
• Clean your desk, door knob, computer, workstation yourself or in your presence
• Keep door opens
• Minimal touching
• Do not touch papers and files, prefer Electronic entries, if feasible
• Wash hands after every patient examination and clean your instruments
especially stethoscope to avoid cross infection
• Avoid lifts, Closed space, Don’t touch lift buttons. Get them cleaned often
• Avoid Heavy load at clinic
• Leave all your stethoscope, knee hammers and other medical stuff in hospital
itself. Don't take home
• Decontaminate car handles

54. While going back home…
• Ring up home when you start from hospital.
• Someone at home should keep the front door open( so that you don't have to touch
the calling bell or door handle) and a bucket of water with soap in the front door.
• Keep things(car keys, pen, sanitizer bottle, phone) in box outside the door.
• Wash your hands in the bucket
• Meanwhile use tissue and sanitizer and wipe the items you have placed in the box
and the box.
• Wash your hands with soap water again
• Now enter the house without touching anything.
• The bathroom door is kept open by someone and a bucket of detergent soap water
is ready. You take off all your clothes including innerwear and soak inside the
bucket
• Then take a head bath with a shampoo and body bath with soap
• Wash your clothes/ put in washing machine with high temperature settings and
dry clothes in direct sunlight

55. ICMR recommendation for COVID-19
Use of hydroxy-chloroquine for prophylaxis for selected individuals as
follows
• Asymptomatic healthcare workers involved in the care of
suspected or confirmed cases of COVID-19:
– 400 mg twice a day on Day 1, followed by 400 mg once weekly for
next 7 weeks; to be taken with meals
• Asymptomatic household contacts of laboratory confirmed
cases:
– 400 mg twice a day on Day 1, followed by 400 mg once weekly for
next 3 weeks; to be taken with meals

56. SUMMARY
• India, being a country of extreme geo-climatic diversity, faces a constant threat of
emerging and re-emerging respiratory infections of public health importance
• COVID–19 is a mutant Corona viral disease which affects the lower respiratory tract
causing respiratory and multi-organ failure leading to death in few patients. Most
(80%) of the infected patients will have a mild disease. Prevention is by Respiratory
Hygiene, Social Distancing, Masks and Chemo-prophylaxis.
• There is a need for strengthening disease surveillance in the country focusing on the
epidemiology and disease burden, also a pressing need to gain detailed insights into
disease bionics, including vector biology and environmental factors influencing the
diseases
• Also, important to strengthen the emergency preparedness for these diseases and
response by focusing on ‘one health’ approach